June, 2016/ Vol 3/ Issue 6 ISSN 2349-5499

Case Report

Management of space in the mixed dentition: The use of lip bumper

Ben Mohimd H1, Benyahia H2, Taleb B3, Zaoui F4

1
Dr Hajar Ben Mohimd, Post Graduate Resident in Orthodontic Department, 2Dr Hicham Benyahia, Assistant Professor
in Orthodontic Department, 3Dr Bouchra Taleb, Professor in Oral Surgery Department, 4Dr Fatima Zaoui, Senior
Professor and Head of Orthodontic Department; all are affiliated with Mohammed V University in Rabat, Morocco.

Address for correspondence: Dr. Ben Mohimd Hajar, Department of Orthodontics, Center of Consultation and Dental
Treatments, Faculty of Dentistry, Mohammed V University in Rabat. Allal El Fassi Avenue, Mohammed Jazouli Street -
Al Irfane City - BP 6212 Rabat Institutes. Morocco. E-mail: hajarbenmohimd@gmail.com
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Abstract
Management of dental space problems continues to play a substantial role in interceptive orthodontics. In the mixed
dentition, moderate crowding problems can be resolved through preservation of the Leeway space, regaining space or
producing limited expansion. The lip bumper is a functional device that is used successfully to intercept developing
dental and occlusal problems by allowing a proper development of the arch length and width for eruption of the
permanent teeth. A nine-year-old female patient with the chief complaint of delayed eruption and lack of space in the left
mandibular quadrant for the eruption of the entire permanent teeth. She was successfully treated in duration of 9 months
with a lip bumper and expansion therapy.

Keywords: Interceptive orthodontics, Management of space, Crowding, Mixed dentition, Lip-bumper device.
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Introduction
Crowding and irregularity remain one of the most
prevalent components of a malocclusion in dental
patients resolved by orthodontic treatment. It is
characterized by an insufficient available space in the
arch for the alignment of the entire permanent dentition.
It can appear at various stages of dentition and can
cause serious periodontal and occlusal consequences.
Therefore, an early diagnosis is important in order to
establish an effective interceptive approach [1]. A
variety of treatment modalities have been described to
gain space in mixed dentition and help to avoid the need
for subsequent extractions. One of these methods is the
lip bumper. It’s a functional device made of .045 inch
stainless steel wire often covered anteriorly with a
plastic or acrylic shield. The wire is fixed to the first
molars bands with a distance of two to three millimeters
away from the incisors and two millimeters away from
the premolars and has adjustment loops located just
mesial to these tubes [2]. The lip bumper can resolve
arch space deficiency either by maintaining the leeway
space at the end of the mixed dentition or by developing
the lower arch.
Manuscript received: 26th March 2016
Reviewed: 10th April 2016
Author Corrected; 24th April 2016
Accepted for Publication: 13th May 2016
The concept behind this appliance is based on the
disruption of the equilibrium surrounding the dentition
by keeping the musculature of the lower lip and cheeks
away from the mandibular teeth, [2] this allows the
lingual forces of the tongue to remain unbalanced,
causing forward and lateral expansion of the
mandibular dental arch. [3] Additionally, the pressure
of the lower lip against the lip bumper during
swallowing is transmitted directly to the lower molars.
This pressure permits the distalization and distal tipping
of the molars leading to arch length increasing [4] [5].
This mode of action not only increases arch dimensions,
but also promotes the adaptation of soft tissues (lips and
cheeks) to the mandibular expansion, thus providing
better long-term stability unlike conventional expansion
techniques [6] [7] [8].
The lip bumper can be used in both the maxillary and
mandibular arch. However, maxillary appliances have
been less frequently used. [9] In fact, R. Hasler and B.
Ingervall [10] reported less effect on the anterior-
pos3erior position of the first molars in maxillary dental
arch compared to the mandibular, which was explained
by the fact that the upper lip is weaker than the lower

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June, 2016/ Vol 3/ Issue 6 ISSN 2349-5499
Case Report

and less likely to generate enough force on the
appliance unless rigorous muscle exercises are
prescribed and followed. The mean pressure at rest
from the lower lip on the lower incisors amounts to 9-
12g/cm2against 2-5g/cm2 from the upper lip on upper
incisors [11] [12] [13].
Regarding the position of the lip bumper in relation to
the incisor crowns, it can be positioned at different
levels. Nevertheless, Hodge et al. [14] measured forces
produced by lip bumpers placed in different positions
and concluded that more force is produced when the
wire lip bumper is placed four millimeters anterior to
the incisors and at a more gingival position.
The lip bumper has been indicated in the mixed
dentition to maintain (molar anchor) or increase arch
length and perimeter, through labial incisors
proclination and molars distalisation, [15] and to
enhance incisor arch form position, when the lower
incisors are lingually positioned (related to hypertonic
lips); but it can also be used in lip habits breaking and
neuro-muscular conditioning. [16].
The Present case report reveals the treatment outcome
of a patient with insufficient space for the eruption of
permanent teeth due to the mesial drift of the left molar
who was treated using the lip bumper device.

Case Report
A 9-year-old female patient referred from Oral Surgery Department, to Orthodontics department located in the Center of
Consultation and Dental Treatments (CCDT), Mohammed V University Rabat, Morocco.The chief complaint was
delayed eruption and lack of space in the left mandibular quadrant, where deciduous teeth extraction (73, 74 and 75) was
made months ago after the decompression of a dentigerous cyst.

Intraoral examination shows a passive space maintainer “lingual arch” which was pointless in this case given that the 36
already moved mesially (loss of anchorage) leading to a slight class III molar relationship. Early extractions of deciduous
teeth has led to spaces loss, midline shift, and bi-retrusion of upper and lower incisors causing important overbite, which
can adversely affect mandibular and facial growth [Figure 1].

Figure 1 a-e: Pre-treatment intra-oral photographs

The panoramic radiograph revealed signs of maxillary canines’ retention, and the mesial displacement of the mandibular
left first molar leading to delayed eruption and retention of canine and premolars [Figure 2]. Cephalometric examination
reveals skeletal Class I malocclusion with hyperdivergent facial pattern tendency hence the importance of early
interception [Figure 3] [Table1].

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June, 2016/ Vol 3/ Issue 6 ISSN 2349-5499
Case Report

Figure 2: Panoramic radiograph showed mesial drift of the left first molar and canine’s retention

Table 1: pre-treatment cephalometric values.

Value * Pre-treatment

SNA 80°

SNB 76°

ANB 4°

AoBo 4mm

UI-NA angle 17°

UI-NA distance 3mm

LI-NB angle 18°

LI-NBdistance 4mm

GoGnSn 38°

PogtoNB 1,25mm

Figure 3: profile teleradiograph

*SNA = Sella–nasion–A point angle; SNB = Sella–nasion–B point angle; ANB = A point, nasion, B point angle;
GoGnSn = Gognion- Gnathion (mandibular plan)–Sella–nasion; UI-NA = upper incisor nasion-A point angle and
distance; LI-NB= lower incisor–nasion-B point angle and distance; PogtoNB = chin prominence – nasion- B point
distance

Treatment objective was at first, to regain mandibular space for eruption of the delayed teeth with the use of a lip bumper
that will help to upright mandibular molar and correct overbite by tipping labially the lower incisors [Figure 4].
Secondly, to expand the maxilla and enhance arch form by setting orthodontic appliance which would be propitious to
the eruption of canines and the harmonization of facial growth [Figure 5].

After 9 months of bumper wear, the device provided a sufficient space for the harmonious eruption of the permanent
teeth [Figure 4]. Then the orthodontic appliance corrected maxillary arch form setting a class I occlusion relationship
awaiting canines’ eruption [Figure 5].

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June, 2016/ Vol 3/ Issue 6
a: lip bumper in place
c: After 6 months
Figure 4: Evolution of the case after lip bumper wear
Figure-5a and 5b: Post-interceptive treatment and orthodontic monitoring of maxillary canines eruption
Discussion
Orthodontists have always been faced with the problem
of straightening crowded teeth. A variety of interceptive
treatment modalities have been advocated in the mixed
dentition to reduce this crowding, some of which
include: tooth extraction, expansion, interproximal
enamel reduction, flaring incisors and uprighting molars
[2].
The lip bumper is an effective appliance which allows
the management of a mild to moderate crowding
(<5mm) by maintaining and/or increasing arch length.
Pediatric Review: International Journal of Pediatric Research
ISSN 2349-5499
Case Report
b: After 3 months
d: After 9 months
[1] Any increase in arch length generally reflects both
distal movement of the molars and labial movement of
the incisors. [17]. In our case, the use of the lip bumper
has allowed at first, the restoration of the space that has
been lost through mesial drift of the molar and
secondly, the anteroposterior and transverse expansion
of the lower arch to ensure the harmonious
accommodation of the erupting teeth.
Several studies were performed to determine the effects
of the lip bumper therapy on mandibular arch
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June, 2016/ Vol 3/ Issue 6
dimensions and to quantify experimental variations.
The effects were discussed under three headings: molar
distalisation, arch width and incisor proclination.
The magnitude and consistency, with which this effect
has been reported, as well as the sources of arch length
increases, vary among observers.
Subtelny and Sakuda [4] reported in a study of twenty-
five cases, a distal molar movement in twenty-two. In
their opinion, the use of the lip bumper in the lower
arch is synonymous with that of a headgear appliance in
the upper arch.
Osborn et al. [15] also quantified several dimensional
changes that occur during the use of the lip bumper. In
their study of 32 patients in the late mixed and earlier
permanent dentitions, they noticed that, an average arch
circumference increased by 4.1 mm and the arch width
by 2 mm at the canines, 2.5 mm at the first premolars,
2.4 mm at the second premolars, and 2 mm at the first
molars. They also reported an increase in the arch
length of 1.2 mm.
Most of the studies of the lip bumper effects in the
lower arch showed that the increase of arch perimeter is
more related to an increase in arch width rather to arch
length. [15][18][19] [20].
In a recent study; where dental casts as well as lateral
and tomographic radiographics were used to determine
the effect of six months of continuous lip bumper
therapy on patients with mild to moderate crowding,
Davidovitch and al. [6] reported more effect on the
molar compared with that remarked with conventional
cephalometry. In fact, they demonstrated that besides
the passive increase in the transverse dimension, arch
length, arch perimeter, and incisor proclination,
mandibular molars tip distally 3.4° and distalize 0.61
mm which allowed the resolution of an average of four
millimeters of crowding more than the control group.
Conclusion
The lip bumper is an effective functional appliance that
is used successfully to intercept developing dental and
occlusal problems [16] and as an adjunct to orthodontic
therapy.
In selected patients with crowded lower arches, the use
of the lip bumper, properly timed and in conjunction
with an accurate diagnosis and complete records, can
Pediatric Review: International Journal of Pediatric Research
ISSN 2349-5499
Case Report
prevent unnecessary loss in arch length by either
maintaining and / or increasing arch dimensions.
In this case report, the use of the lip bumper did ensure
the gain of space through the distal movement of the
molarsand the incisors. This gain of space allowed on
one hand a harmonious development of permanent teeth
and on the other hand to eliminate the need for
subsequent extraction during permanent dentition.
Funding: Nil, Conflict of interest: Nil
Permission from IRB: Yes
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How to cite this article?
Ben Mohimd H, Benyahia H, Taleb B, Zaoui F. Management of space in the mixed dentition: The use of lip bumper. Int
J Pediatr Res.2016;3(6):440-445.doi:10.17511/ijpr.2016.i06.12.
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Pediatric Review: International Journal of Pediatric Research
ISSN 2349-5499
Case Report
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